– by Maureen Palmer & Mike Pond
As Fentanyl overdoses make headlines coast to coast, it’s clear that there is an urgent need for effective, evidence-based treatment. But Fentanyl isn’t the only issue: in Canada, alcohol misuse is a much bigger problem.
According to Dr. Gregory Tayler, Canada’s Chief Public Health Officer, “approximately 5 million Canadians (or 18 per cent of the population) aged 15 years and older met the criteria for alcohol abuse or dependence at some point in their lifetime.”
We are surrounded by evidence that alcohol use causes serious physical and mental health harm. So why is a support group — that works for 30 per cent of participants, at best — the dominant form of treatment?
In January, our book Wasted: An Alcoholic Therapist’s Fight For Recovery in a Flawed Treatment System was published. It captures my partner Mike Pond’s devastating trip to rock bottom and back; a journey that left him with unique insight into Canada’s deplorable addiction treatment system.
Also in January, our film following Mike’s search for evidence-based treatment (the standard we apply to rest of health care, but lacking in addiction) aired on The Nature of Things documentary Wasted. Since then, we’ve received hundreds of calls and emails from desperate Canadians trying to save the life of someone they love — who can’t find effective treatment. Since September is Recovery Month, we offer these suggestions to stop the hemorrhage of tax dollars and the waste of lives:
1. We need standardized, compassionate, evidence-based care for all battling substance-use disorders.
In Canada, treatment of addiction — a complex medical disorder often accompanied by other serious mental illnesses like bipolar disorder — is often left to churches and charities staffed by lay people or people with minimal training. Or to high-end treatment facilities that are too expensive and out of reach for most Canadians. The dominant treatment is the 12-step model: support groups. Many participants credit their well-being today with their involvement in AA or similar groups.
Support groups have worked for millions of people, but they don’t work for the majority. We now have a broad range of treatments that have clinically proven to be effective, including medications, meditation, cognitive behavioural therapy, motivational interviewing and trauma counseling. We know a significant portion of people battling substance-use disorders have suffered trauma; treating trauma requires expertise not available in most recovery facilities. Treatments beyond support groups dramatically up the chances of recovery.
We also have no way to compel the largely 12-step abstinence-only support community to offer alternatives.
2. All treatment providers must provide a range of evidence-based options.
We suggest governments no longer publicly fund programs that rely exclusively on AA or 12-step models. Controlled studies have shown that these programs, while effective for some, are no better than offering no treatment at all. And in many of these programs, participants battling substance use experience shame and humiliation, which is proven to make addiction worse. The compassion shown to those suffering from physical illness must be extended to those battling substance use disorders.
3. Canada must adopt harm reduction in all addiction prevention, education, research and treatment.
A strong body of clinical and social science research tells us harm reduction is cost-effective and proven to save lives, while abstinence is an ineffective measure of success: too many “fail” to meet that standard. By using evidence-based treatments, clinicians can offer treatment in stages, starting with safer use and harm reduction at the front end and leading to evidence-based approaches to abstinence at the back end. Offer a continuum rather than one or the other.
4. Urgent life-saving addiction treatment must be as accessible as any other serious health treatment.
No one’s child should die in a Starbucks because of long wait lists for addiction treatment — this would not have happened if that child had cancer. No one should go to an ER 31 times, as Mike did, suffering from end-stage alcohol use disorder, and receive only Ativan and a bus pass.
5. Cost must no longer be a barrier to treatment.
Without clear standards and regulation, Canada has a three-tier treatment system. At the low end: run-down recovery homes that house people with mentally illnesses, those battling concurrent disorders, court-ordered offenders and the destitute. In the middle: government-funded agencies with long waits. At the high end: private rehabs that charge $20,000 to $60,000 a month. No one in Canada should have to mortgage their home for treatment (especially when the treatment is based on methods proven ineffective for most). We do not ask this of people facing any other life-threatening disorder.
6. Adequately trained professionals must deliver treatment.
Addiction is a complex mental disorder requiring clinical and medical expertise, yet treatment is often delivered by laypeople who rely on their own sobriety as their main expertise. A valuable tool to be sure, but not enough to treat a life-threatening condition. Mike relapsed at a government-funded program and the “group conscience,” (his fellow clients) voted him out. He ended up alone on White Rock beach in the worst November snowstorm to hit the lower mainland in decades. His disorder only got worse from there. He almost died.
Experts believe the lack of professionalism in treating this major disorder contributes to high relapse rates, fails to recognize or treat concurrent mental disorders and results in too many senseless deaths. At a minimum, counsellors should have their master’s degrees and medical staff should be certified in evidence-based addiction treatment.
7. Canada’s doctors must be educated in evidence-based addiction care.
Many doctors are unqualified, inadequately trained or refuse to diagnose or treat addiction. From Mike’s clients’, we’ve heard dozens of examples of physicians refusing to prescribe naltrexone, a drug that’s been available for two decades to help battle cravings. Primary care does a great job with diabetes and hypertension. Doctors must be trained to treat addiction too.
8. Early screening and brief intervention be adopted nation-wide.
Everyone from high school guidance counselors, nurses, social workers, ER physicians and family doctors can provide this 5 to 15-minute assessment, which has been proven to positively change substance-using behaviours. In addition, it can identify and improve the probability of an early diagnosis of a mental disorder. Early screening and brief intervention saves lives.
9. Stop criminalizing a health issue.
Addiction, often with a concurrent mental disorder, is disproportionately present in prisons. In 2009, Mike spent a few weeks in the Fraser Regional Correctional Centre for drunk driving related offences. He estimates three-quarters of his fellow inmates were there for addiction-related crimes. There is no more expensive way to pay for addiction.
10. Judges should stop requiring abstinence or abstinence-based treatment as sentencing conditions.
Forcing anyone to attend a “voluntary” treatment undermines the most effective part of the treatment: that someone wants to there. What’s worse, these sentences are served in places where there are no standards and where many residents openly use. This pretty well guarantees they’ll re-offend, which means more arrests, more money wasted on courts and prisons, while never solving the problem.
Why don’t we have an addiction treatment system that’s part of the public health system? We believe it’s because too many still think addiction is a moral problem, not a medical one. Regardless, the evidence mounts all around us: whatever we are doing, it is not working.
For those who got well using AA, we applaud you. Please do not mistake our quest for better treatments for all as criticism of your success, or seeking “the easier, softer way” — a sentiment we often hear voiced in AA circles. It’s recognizing the fact that others simply need a different approach to get well, with no judgment of how they get there. The founder of AA never wanted their support group to become a mandatory, one-size fits all approach. In fact, Bill W. and Dr. Bob encouraged science to study alcoholism and come up with medical solutions.
Those solutions are now upon us. It is way past time to use them.